Abdominal Pain

No National or International Guidelines available. 

Cochrane Reviews

Antidepressants for the treatment of abdominal pain-related functional gastrointestinal disorders in children and adolescents.

Kaminski A, Kamper A, Thaler K, Chapman A, Gartlehner G. Cochrane Database of Systematic Reviews 2011, Issue 7.

Summary: 

Abdominal pain-related functional gastrointestinal disorders (FGIDs) are common in childhood and adolescence. In most cases no medical reason for the pain can be found. Various drug treatment approaches for the different types of abdominal pain-related FGIDs exist. These drug treatments include: prokinetics and antisecretory agents for functional dyspepsia; pizotifen, propranolol, cyproheptadine or sumatriptane for abdominal migraine; and antispasmodic and antidiarrhoeal regimen for irritable bowel syndrome. Antidepressants have been shown to be effective in some studies of adults with functional gastrointestinal disorders. As a result young patients with similar complaints are sometimes treated with antidepressants. The purpose of this review was to examine the evidence assessing the advantages and disadvantages of such an approach. Only two studies met the inclusion criteria. Both of these studies were randomised controlled trials and assessed the effectiveness and safety of amitriptyline in children with FGIDs. Amitriptyline is a first generation antidepressant (tricyclic antidepressant). Amitriptyline is no longer an agent of first choice for the treatment of depressive disorders because of potentially serious side effects including overdose. Amitriptyline has not been approved for the treatment of functional abdominal pain in children or adolescents.

The larger study (n = 90) showed no difference in the proportion of patients feeling better between the treatment - and the placebo (sugar pill) groups. Side effects were mild and included fatigue, rash and headache and dizziness.The authors of the other, much smaller study (n = 33) reported a significant improvement in overall quality of life and a reduction in pain for specific areas of the abdomen and certain follow up times. However, the results of this study should be interpreted with caution due to poor methodological quality and the small number of patients enrolled. Amitriptyline does not appear to provide any benefit for the treatment of FGIDs in children and adolescents. At present, the evidence for the treatment of children and adolescents with abdominal pain-related diseases with antidepressants does not support the use of antidepressant agents in this group of patients. We suggest considering alternative treatments that are supported by stronger evidence. There is need for larger, well-conducted trials with adequate patient relevant outcomes such as quality of life and pain relief to provide more information regarding this common condition.

Psychosocial interventions for recurrent abdominal pain (RAP) and irritable bowel syndrome (IBS) in childhood.

Huertas-Ceballos AA, Logan S, Bennett C, Macarthur C. Cochrane Database of Systematic Reviews 2008, Issue 1.

Summary:

Between 4% and 25% of school age children complain of stomach aches / recurrent abdominal pain (RAP) which is severe enough to interfere with their daily activities. For most such children, no organic cause for their pain can be found on physical examination or investigation. Although most children are likely to be managed by reassurance and simple measures, a large range of interventions including dietary manipulation, some medicines and psychological interventions has been recommended. Recently it has been suggested that children previously described as having RAP should be classified according to the pattern of symptoms into a series of sub-groups (the Rome II criteria) including irritable bowel syndrome, functional dyspepsia, functional abdominal pain and abdominal migraine. It is not clear whether these categories describe conditions that really differ in either aetiology or responsiveness to treatment . This review attempted to determine the effectiveness of psychosocial interventions. We found 6 studies (including 167 children), all of which examined interventions broadly based on cognitive behavioural therapy (CBT) and no trials of other types of psychosocial interventions. Five of these trials had interpretable results, although lack of important data and / or clinical differences in either intervention or control groups prevented us from combining them statistically. The included trials were relatively small and had some weaknesses in design and reporting. Each of the included studies reported a statistically significant benefit to participants in the intervention group. CBT may therefore be worth considering for some children with recurrent abdominal pain, but this review points to the need for further, better-quality research.

Acupuncture for treatment of irritable bowel syndrome.

Manheimer E, Cheng K, Wieland LS, Min LS, Shen X, Berman BM, Lao L. Cochrane Database of Systematic Reviews 2012, Issue 5

Summary: 

This review included 17 randomized controlled trials (RCTs) including a total of 1806 participants. Five RCTs (411 participants) compared acupuncture to sham acupuncture for the treatment of IBS. Sham acupuncture is a procedure in which the patient believes he or she is receiving true acupuncture. However, in sham acupuncture the needles either do not penetrate the skin or are not placed at the correct places on the body, or both. Sham acupuncture is intended to be a placebo for true acupuncture. The sham-controlled studies were well designed and of high methodological quality. These studies tested the effects of acupuncture on IBS symptom severity or health-related quality of life. None of these RCTs found acupuncture to be better than sham acupuncture for either of these two outcomes, and pooling the results of these RCTs also did not show acupuncture to be better than sham acupuncture. Evidence from four Chinese language comparative effectiveness trials showed acupuncture to be superior to two antispasmodic drugs (pinaverium bromide and trimebutine maleate), both of which provide a modest benefit for the treatment of IBS, although neither is approved for treatment of IBS in the United States. It is unclear whether or not the greater benefits of acupuncture reported by patients in these unblinded studies are due entirely to patients’ greater expectations of improvement from acupuncture than drugs or preference for acupuncture over drug therapy. There was one side effect (i.e. fainting in one patient) associated with acupuncture in the nine trials that reported side effects, although relatively small sample sizes limit the usefulness of this safety data.

Psychological treatments for the management of irritable bowel syndrome.

Zijdenbos IL, de Wit NJ, van der Heijden GJ, Rubin G, Quartero AO. Cochrane Database of Systematic Reviews 2009, Issue 1.

Summary: 

In this review, the effectiveness of psychological therapies for adult patients with irritable bowel syndrome was evaluated. Studies involving cognitive behavioural therapy, interpersonal psychotherapy and relaxation therapy or stress management were reviewed. Although it is difficult to draw conclusions because of differences between studies and quality issues, the results suggest that cognitive behavioural therapy and interpersonal psychotherapy may be effective immediately after finishing treatment. It is unclear whether the effects of these therapies are sustained thereafter. These results have to be interpreted with caution as the quality of the studies was sub-optimal. Physicians should be aware of the limitations of these therapies and should choose an appropriate therapy based on the individual patient's characteristics.

Celiac plexus block for pancreatic cancer pain in adults.

Arcidiacono PG, Calori G, Carrara S, McNicol ED, Testoni PA. Cochrane Database of Systematic Reviews 2011, Issue 3

Summary: 

Abdominal pain is a major symptom in patients with inoperable pancreatic cancer and is often difficult to treat. Celiac plexus block (CPB) is a safe and effective method for reducing this pain. It involves the chemical destruction of the nerve fibres that convey pain from the abdomen to the brain. We searched for studies comparing CPB with standard analgesic therapy in patients with inoperable pancreatic cancer. We were interested in the primary outcome of pain, measured on a visual analogue scale (VAS). We also looked at the amount of opioid (morphine-like drugs) patients took (opioid consumption) and adverse effects of the treatment. Six studies (358 participants) comparing CPB with standard therapy (painkillers) met our inclusion criteria. At four weeks pain scores were significantly lower in the CPB group. Opioid consumption was also significantly lower than in the control group. The main adverse effects were diarrhoea or constipation (this symptom was significantly more likely in the control group, where opioid consumption was higher). Endoscopic ultrasonography (EUS)-guided CPB is becoming popular as a minimally invasive technique that has fewer risks, but we were not able to find any RCTs assessing this method (current medical literature on this subject is limited to studies without control groups). Although the data on EUS-guided CPB and pain control are promising, we await rigorously designed RCTs that may validate these findings. We conclude that, although statistical evidence is minimal for the superiority of pain relief over analgesic therapy, the fact that CPB causes fewer adverse effects than opioids is important for patients.

 

 

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